Appraising the situation: a framework for understanding ...

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warwick.ac.uk/lib-publications Original citation: Tierney, Stephanie, Seers, Kate, Reeve, Joanne and Tutton, Elizabeth. (2017) Appraising the situation : a framework for understanding compassionate care. Journal of Compassionate Health Care, 4 (1). Permanent WRAP URL: http://wrap.warwick.ac.uk/84891 Copyright and reuse: The Warwick Research Archive Portal (WRAP) makes this work of researchers of the University of Warwick available open access under the following conditions. This article is made available under the Creative Commons Attribution 4.0 International license (CC BY 4.0) and may be reused according to the conditions of the license. For more details see: http://creativecommons.org/licenses/by/4.0/ A note on versions: The version presented in WRAP is the published version, or, version of record, and may be cited as it appears here. For more information, please contact the WRAP Team at: [email protected]

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Original citation: Tierney, Stephanie, Seers, Kate, Reeve, Joanne and Tutton, Elizabeth. (2017) Appraising the situation : a framework for understanding compassionate care. Journal of Compassionate Health Care, 4 (1). Permanent WRAP URL: http://wrap.warwick.ac.uk/84891 Copyright and reuse: The Warwick Research Archive Portal (WRAP) makes this work of researchers of the University of Warwick available open access under the following conditions. This article is made available under the Creative Commons Attribution 4.0 International license (CC BY 4.0) and may be reused according to the conditions of the license. For more details see: http://creativecommons.org/licenses/by/4.0/ A note on versions: The version presented in WRAP is the published version, or, version of record, and may be cited as it appears here. For more information, please contact the WRAP Team at: [email protected]

ORIGINAL RESEARCH Open Access

Appraising the situation: a framework forunderstanding compassionate careStephanie Tierney1*, Kate Seers1, Joanne Reeve2 and Liz Tutton1

Abstract

Background: Compassion in healthcare represents an ideal way of interacting with patients. It entails an activeresponse to suffering, distress or discomfort that can be associated with people seeking health related support ortreatment. However, reports from within healthcare highlight that compassionate care (CC) is not always achieved.It may be especially problematic when trying to work with a patient who seems unwilling or unable to engagewith advice provided by a healthcare professional (HCP).

Methods: We conducted a grounded theory study to understand the meaning of CC for HCPs working withpatients with type 2 diabetes. Data were collected between May-October 2015 using focus groups and individualinterviews; 36 HCPs took part in total. For the current paper, we used constant comparison to analyse data fromtranscripts where participants talked about working with a ‘non-adherent’ patient.

Results: Analysis highlighted how appraisal of their encounter with a non-adherent patient could affect whetherCC was seen as possible by participants. Therefore, we used a transactional model of emotions as a framework forunderstanding HCPs’ narratives. This involved a consideration of their primary appraisal of such encounters, whichparticipants said often resulted in a sense of threat, failure and rejection. Their secondary appraisals, which centredon coping resources, included problem-focused approaches (e.g. supporting the patient to plan how to moveforwards in managing their health) and emotion-focused approaches (e.g. recognising change was hard,appreciating it may not be the right time for the patient to change). These appraisals could be modified by: a)gaining experience as a HCP; b) altering what was seen as professional success; c) their connection with thepatient; d) how much autonomy they had in their job.

Conclusions: Our findings provide new insights and emphasise that CC in response to non-adherent patients isnot determined solely by a HCP’s innate nature, but can be affected by an individual’s appraisal of this interactionand the resources he/she has available to cope. This has implications for the environment within which staff work.

Keywords: Grounded theory, Compassionate care, Non-adherence, Transactional model of emotions, Interviews,Focus groups

BackgroundAt the start of the 21st Century, concern about a per-ceived decline in compassion within healthcare has beenreflected in numerous articles in the media, academicpublications and policy documents. Yet despite thisplethora of recent writing, there has been “little curiosityabout what compassion, especially in healthcare, actuallyentails. How does it work? How is it nourished? Whatdoes it involve for staff? Why is it hard to sustain?” [1].

Compassionate care (CC) is often presented in an ideal-istic form - as something that simply and automaticallytakes place, but this superficial consideration of the con-cept means that CC risks being “little more than a rhet-orical and political device” [2], rather than a conceptthat can change/improve how services are delivered andexperienced. Therefore, we urgently need fresh insightsand new thinking around this key aspect of healthcare.Definitions of CC vary [e.g. 2–4], but most recognise a

core role for the relief of suffering (distinguishing CCfrom related concepts such as empathy, sympathy andpity). Gilbert and Choden [5] describe two processes

* Correspondence: [email protected] College of Nursing Research Institute, University of Warwick, Coventry,EnglandFull list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Tierney et al. Journal of Compassionate Health Care (2017) 4:1 DOI 10.1186/s40639-016-0030-y

associated with compassion: a) an ability to be open,alert, sensitive to suffering, and b) taking action to dosomething to alleviate or prevent this state. Existingwriting on CC often focuses on attitudes, beliefs and ac-tions of individual healthcare professionals (HCPs).However, our research has highlighted the importance ofrecognising CC as a complex model of care – a systemwide process that needs to acknowledge both the actionsof HCPs alongside the relationships and environment inwhich these occur [6].In this article, we seek to advance understanding of CC

by considering a critical situation [7] that emerged withinour recent research. Whilst analysis revealed the import-ance of organisational factors in enabling or disrupting CC,participants also mentioned a particular patient factor thatmade CC challenging; they spoke of the difficulty in main-taining CC for patients they perceived to be ‘non-adherent’to medical recommendations (they used this term, ratherthan concordance, so we have also employed it within thepaper). This critical situation offers potential for deeperexploration of staff understanding and motivation fordelivering CC through an examination of the importance ofattributions and coping responses when faced with suchencounters.

MethodsDesignFindings in this paper are based on data generated from agrounded theory study exploring the meaning of CC forHCPs working with patients with type 2 diabetes. Itfocused on care for this condition because it calls forsustained patient interaction with health services, allowingfor on-going opportunities for compassion to be offered -or not. A presentation of a whole systems model we devel-oped from this study, which recognises the complexdynamics enabling or inhibiting CC, has been describedelsewhere [6]. The current paper presents an in-depthreflection on a single topic from the primary analysis -namely what participants said about CC and their interac-tions with non-adherent patients. This was prominentwithin the data we collected in terms of intensity offeelings raised and its regular depiction as a barrier to CC.

SampleWe used a purposive sampling approach initially, seekingmaximum variation in terms of HCPs’ experience, role(professional and support workers) and location of work(primary and secondary care). As data collection pro-gressed, theoretical sampling was employed to find profes-sionals who were newly qualified because people suggestedtheir understanding of CC evolved as they became moreexperienced in their career. Participants worked across theUK and were recruited from two NHS Trusts and fromrelevant networks (e.g. Diabetes UK).

Data collectionParticipants opted to engage in an individual interview or afocus group. Data collection took place during May–October2015. Everyone gave informed consent to their involve-ment and to use of their anonymised quotations as part ofdissemination. A topic guide was employed during inter-views and focus groups, which outlined key areas to cover.Participants were asked questions such as:

� What do practitioners do to show compassiontowards patients?

� How do you feel when you have been able to showcompassion?

Data were audio-recorded and transcribed verbatim.All data collection was conducted by the first author;she does not have a clinical background and did notknow participants prior to the study.

AnalysisThe primary analysis used principles from grounded theory[8], including initial and focused coding, writing memosand constant comparison, to develop the full model. Afocused code emerging from this analysis was ‘facing non-changing patients’. All data extracts (n = 87) assigned thislabel by the research team within the computer programmeNVIVO were downloaded and reviewed. We undertook asecondary analysis of this specific code, informed byconsideration of a framework developed by Lazarus andFolkman [9], who suggested that to understand emotions itis important to look at the transaction between person andenvironment:

“Threat, for example, is not solely a property of theperson or the environment; it requires theconjunction of an environment having certainattributes with a particular kind of person who willreact with threat when exposed to thoseenvironmental attributes.”

Their model centres on the idea that how someoneresponds to an encounter is mediated by their interpret-ation of it on two levels:

� Primary appraisal: What does the situation meanfor me? Is it a potential harm, threat, benefit orchallenge? This can be shaped by how much stakeindividuals feel they have in an encounter, theirpersonal motivations (goals, values) and beliefsabout self and the world [9], which in turn affectsthe quality and intensity of their emotional response.

� Secondary appraisal: Can I cope? What resourcesare at my disposal? What control do I have overoutcomes from this interaction? Hence, emotional

Tierney et al. Journal of Compassionate Health Care (2017) 4:1 Page 2 of 8

response to a situation can be shaped by whethersomeone regards it as an encounter that: “(1) couldbe changed; (2) had to be accepted; (3) requiredmore information before acting; (4) required holdingoneself back from doing what one wanted to do” [9].Lazarus and Folkman [9] wrote about a range ofcoping responses, including: confrontive, distancing,self-control, seeking social support, accepting re-sponsibility, escape-avoidance, planful problem-solving, positive reappraisal. These can be dividedinto two broad coping approaches – problem-focused (addressing a facet of the problematicperson-environment relationship) and emotion-focused (attempting to regulate feelings).

In line with this model, our data extracts were labelledas either primary or secondary appraisal by the first au-thor; we also had the label ‘modifier’, which is not part ofLazarus and Folkman’s model [9], but as described belowappeared to be present within our data. The first authordiscussed her ideas with the rest of the team (who havea mixture of clinical and academic experience) to arriveat the findings presented below.

RigourTo address rigour within the overall study, more than oneperson, from a range of backgrounds, took part in the ana-lysis. In addition, NVIVO was used to manage and recorddecisions made throughout the research, providing a clearaudit trail. We continued recruiting until we had gathereddata from HCPs reflecting a range of perspectives in termsof role, experience and work setting.

ResultsInterviews were conducted with 13 HCPs; they lasted be-tween 40 and 75 min. In addition, 4 focus groups wereheld, involving 23 people in total, which lasted between 40and 80 min. Two focus groups were attended by a mixtureof HCPs, another with nurses and the last one was withpodiatrists. Overall, 13 nurses (including specialist nurses),seven doctors (including consultants and general practi-tioners), six podiatrists, five healthcare assistants/supportworkers, three dieticians and two administrative staff par-ticipated in the study. Half worked in a hospital and theremainder in primary care or the community.Participants taking part in focus groups (FG) and in-

terviews (Int) described how facing a patient not makingchanges to their lifestyle could affect negatively their de-livery of CC:

FG4 P8: “…it’s frustration that they don’t helpthemselves and it’s very difficult to be compassionatewith somebody who won’t do anything to helpthemself.”

Int 6: “…it does wear you down…when you see thesame patient and nothing’s happening…I would saythat compassion, I wouldn’t say it disappears…but itdoes go down quite a bit.”

They were also clear that what was perceived as CCwas not consistent and could shift from person to per-son and situation to situation:

FG3 P1: “…my perception of compassion and a doctor’sconception of compassion may be two completelydifferent things and a patient sitting there might favourone or the other. So what I would construe ascompassion actually may not always be right.”

As noted above, these descriptions of the variablenature of CC and the difficulties encountered whenworking with non-adherent patients were re-analysedusing Lazarus and Folkman’s framework [9] to pro-vide a fresh insight on this topic. A summary of howthis model captured the essence of what participantssaid is illustrated in Fig. 1. This is elaborated uponbelow and is the first time, to our knowledge, thatthis model has been used for thinking about howHCPs approach the provision of CC. Within thispaper, we add to the model by considering factorsthat may modify appraisals of non-adherent patients,thereby affecting whether or not CC is expressed.

Applying the transactional modelPrimary appraisal: When working with individuals whoseemed unwilling or struggled to manage their condi-tion, participants’ primary appraisals included seeingthe situation as a threat or potential harm to theirsense of self as caring, to the positive feedback theyanticipated from trying to help others, and/or to theirprofessional reputation. Hence, they talked about be-ing treated unfairly or taken for granted, feeling stuckor not getting their message across, having their ad-vice rejected or not meeting professional goals ofhealing or improving someone’s situation. They oftenmentioned feeling like a failure in such cases, againreflecting a perceived threat to their professional andpersonal sense of competence. Quotations illustratingthese observations are presented in Table 1.Only one person talked about seeing these patients as

a positive challenge, which she related to personal ratherthan professional goals:

Int 8: “I’m a pleaser. I like to please….I often keeppatients I find a challenge cause I like to bringthem, get them to change. That’s part of mypersonality…I’m a completer/finisher and I amcompetitive as well…”

Tierney et al. Journal of Compassionate Health Care (2017) 4:1 Page 3 of 8

Secondary appraisal: In terms of secondary appraisals,problem- and emotion-focused coping processes were de-scribed. Problem-focused, as outlined in Table 2, includedstressing the reality of what might happen if people didnot control their blood sugars through education and in-formation, and devising a plan about how to help by un-derstanding someone’s personal situation and goals.

They also mentioned being thwarted in their endeav-ours to help, feeling powerless to change a situation andlacking time to understand a patient’s decision-making.This could result in more emotion-focused coping, suchas recognising how altering behaviour is hard, as is livingwith diabetes, appreciating it may not be the right timefor someone to change, drawing on colleagues for sup-port, celebrating small goals and believing they had donetheir best. Data reflecting these coping approaches arepresented in Table 3.

Fig. 1 The transactional model of emotions and how it relates to compassionate care (CC) when healthcare professionals (HCPs) interact withpatients they perceive to be non-adherent

Table 1 Data extracts highlighting primary appraisals of non-adherent patients

FG4 P8: “…you’re not going to feel particularly compassionate towardspeople who are just not taking on board very simple advice, which willprevent them being the ones we see every week.”

Int 4: “…you feel like then that you’ve failed if you’ve maybe not gotthat message across…it does make you feel like you’ve not done a verygood job…”

Int 5: “…it’s upsetting from a clinician’s point of view because youalways want to see people improving.”

Int 6: “…we hate to see patients that are sort of not joining in withwhat we’ve said and we know the benefits from it so it does get veryhard…I suppose it’s just the fact that they haven’t really took on boardmuch that you’ve said.”

Int 9: “…you’ve come to a brick wall…if they’re not getting better orthings are not improving, where do you actually go from there?”

Int 13: “That’s frustrating…because medically speaking you want to dothe best for the patient and the best means that their sugar levels needto be down…”

Table 2 Data extracts highlighting problem-focused coping

FG2 P1: “I guess it’s again communicating, going back to the start andworking out why they haven’t followed that method.”

FG4 P3: “Sometimes you have to try scare tactics when you’ve had somany incidents and problems, you can say I know what this is gonnalead to if you carry on – amputation…I resort to that sometimes if I’mnot getting through to them.”

Int 3: “I think it’s just trying to understand where that person is at themoment and what they are physically capable of and just saying…well Iappreciate that and in the ideal world this, this and this should happen,but actually today we’ll concentrate on this one element.”

Int 9: “It’s trying to tease out from them what changes they are willingto do, what’s realistic for them and working with them…bring thatmotivation in…at the end of the day you can only do what you can doand being practical about things that you can change.”

Tierney et al. Journal of Compassionate Health Care (2017) 4:1 Page 4 of 8

Appraisal of the situation (personally and professionally)and whether one had the requisite skills to cope appearedto contribute to an acceptance of patients’ unwillingnessto change, with a compassionate response described asremaining available in such circumstances:

Int 2: “…you can’t push against a closed door. I justsay when you’re ready, remember these things arehere and that’s what we’re here for…”

Yet, in some cases, withdrawal could occur, to allowfor emotional containment. One person said she some-times retreated to her “professional shell” (Int 3) whenfaced with such cases. This was described as necessaryso she could move on and attend to the needs of herwider caseload. CC was, therefore, replaced with a pro-fessional need to continue with tasks; consequently, astate of detachment might ensue:

FG4 P8: “…you do put your professional hat back onand say…well you know you shouldn’t be doing x, yand z…and that’s when you do pull back…I do find itvery hard to be compassionate with them whenthey’re just, they just don’t give a damn.”

Alternatively, emotional labour [10] was performed inorder to make patients feel at ease despite HCPs’ frustra-tion. Emotional labour entails altering or hiding howone really feels for the benefit of others and prioritisingtheir need for safety and happiness [11]. The followingquotations indicate this may happen when faced with anon-adherent patient, during which CC was enacted:

FG2 P3: “…patients are all different and some you willjust bite your lips…”

Int 3: “…sometimes, the first thing is oh for God’ssake, we told you. We discussed this…You can feelthat but the patient shouldn’t know that.”

Int 4: “You are tantamount to being an actresssometimes as a nurse. You do kind of put on this faceand this picture and you just get on with it.”

Modifiers of appraisals: Narratives suggested that howHCPs appraised a situation and their ability to copechanged over time; as they gathered more experience intheir work role, most participants appeared able toaccept what was possible and were comfortable in draw-ing support from colleagues:

Int 9: “I think I’m more of a doer now. Before I wouldbe worrying about things and not being practicalabout OK, what can I do about this? I’ve got moreconfidence now to go and speak to somebody aboutthings or more experience because I’ve had othercases that I can compare it to…when I first startedworking 7 years ago, things I would have maybe gotquite upset about or maybe taken home with me orworried about…7 years later I’m able to handle a bitbetter and maybe able to give a bit more advice andsupport because I’ve been through it maybe withother people.”

One person talked about changing her view of whatconstituted success in her role as a nurse, which helpedher to alter her primary appraisal of non-adherent pa-tients as a threat:

Int 1: “…in my early days of nursing…people werecoming back to see me and it was as if I hadn’t helpedthem at all…I remember vividly wanting to walk awayfrom diabetes nursing because I couldn’t get it right. Ireally felt that I was failing people…I don’t get crossnow because I look at it through a differentperspective…I’ve rephrased what success is for me.Success isn’t the person in front of me does the rightthing and gets the right target…the success for me isthat they’re happy with it…So success is about theview of the person around what they’ve achieved…”

The situation could also be appraised differently de-pending on how connected HCPs felt with a patient.

Table 3 Data extracts highlighting emotion-focused coping

Int 2: “I’ve come to recognise we can make small strides and where wemake them we should celebrate them…but there are some people youcan’t, sometimes the people you really can’t motivate at all is becauseyou cannot change their life situation.”

Int 6: “…you have to realise that you’re not gonna win everything andhow far you can go with that patient, they have to make that changethemselves.”

Int 9: “…kind of an open door policy with [colleagues] that you feel youcan go and talk to them at any time if you’ve got a problem. I thinkthat’s been very important in my professional career that I’ve gotsomebody that I can approach and talk to and not feel that I’ll bejudged in anyway.”

Int 10: “…change is slow for some people and you just have to beprepared to go at their pace and some people will never change and Ithink it’s their choice.”

Int 11: “I do take into account the massive life changing things thatwe’re asking patients to do and it is difficult and it’s not something theycan do for a couple of months and then go back to their previouslifestyle.”

Int 13: “I would always look to get extra help from my team or maybejust discuss with a colleague as to what we can do for differentpatients.”

Tierney et al. Journal of Compassionate Health Care (2017) 4:1 Page 5 of 8

Those participants (particularly specialist nurses and podi-atrists) who saw patients on a regular basis felt that thisprevented them from interpreting someone’s behaviour asa threat because they knew the person well and felt theycared for her/him as an individual, not just a condition:

FG4 P8: “…the ones that we’re really seeing regularly,we may feel differently towards the ones that come infor their annual review…you get into conversations,well what are you doing wrong and what are yougetting right…So your levels of compassion alter incorrespondence to the type of appointment…”

FG4 P1: “…those patients that become your favouritesthat you really care about, you do have unconditional[compassion] with them…some patients you really docare what happens to them so you will always keepgoing.”

Nevertheless, these patients could come to be ap-praised as a threat if they were felt to be too dependent:

Int 4: “On a negative respect, people become quiteclingy and oh well I only want to speak to so and so.So it’s challenging to make sure that you’ve not madeyourself indispensable because you have to have a dayoff, you have to go home.”

Int 8: “But she’s started to cling, you know, theywhat’s the word when they start to cling to theprofessional, so she is standing out currently. I havehad a few like that and to break that connection so itdoes remain professional…”

As well as length of time someone had to spend withpatients, another potential modifier of HCPs’ appraisalswas the autonomy they had within their role and whetherthey felt able to change the structure of their working day:

Int 2: “I’ve had situations where the work pressuresare, you know, really mounting up but I would like tothink that I always make time [to talk to patients whoare struggling]…I can set my own timetable a lotmore and I can also quite often these scenarios wouldcome up where the patient’s not in a clinical, a clinicsituation so we can expand what we’re doing.”

DiscussionCompassion is part of health terminology that peopledraw on to make sense of how to conduct themselves in

a professional caring context. Data reported in thispaper highlight that CC may be constructed in differ-ent environments in different ways, depending on in-dividuals’ appraisal of the situation before them.Hence, two people may vary in their response to thesame encounter or the same person may reappraisewhat takes place in light of new information or re-sources. This dynamic is not necessarily reflected inpolicy documents that simply decree a need for CC[12]. In this sense, our research makes a novel contribu-tion to debate on this topic by presenting CC through thelens of Lazarus and Folkman’s transactional model [9].Specifically, we drew on their notion of primary and sec-ondary appraisals, and considered how, in relation to CC,these could be modified depending on interpersonal andcontextual factors. Specific points highlighted by this workare outlined in Table 4.Our research highlighted that a key factor affecting

HCPs’ appraisal of non-adherence is the environment inwhich they work. It has been noted that if a sense ofperil or risk predominates, with a focus on outputs andtargets, a “production-line mentality” may ensue, imped-ing people’s psychological capacity for compassion [13].Hence, although CC is said to call for an understandingof why someone may not follow medical advice andbeing able to imagine what a patient is going through[14], HCPs may lack the time to appreciate a person’sunique situation and what diabetes means to him/her;consequently, they may appraise non-adherence as a sig-nificant threat to their professional proficiency and abil-ity to help.Perceiving non-adherence as a threat can prevent

HCPs from ‘being with’ patients, whereby both partiesco-operate and work together. This was emphasised dur-ing data collection by participants’ actual use of the term‘non-adherent’, which infers a privileging of HCPs overexperiential knowledge. In contrast, concordance impliesthat an exchange about a condition’s management hastaken account of how to integrate self-care into a pa-tient’s unique life circumstances and activities [15]. Inthis sense, concordance is seen as patient-centred [16],whilst adherence may mean agreeing with a HCP’s

Table 4 Key leaning points from our analysis (see also Fig. 1)

• For CC to be exhibited requires more than an inner drive within anindividual HCP.

• Delivery of CC can be affected by appraisal of an immediate situation,what it means to self and professional identity, and what resourcesHCPs feel are available to them.

• Certain environmental or interpersonal factors can modify how HCPsappraise their interaction with a non-adherent patient; this has implicationsfor CC delivery.

• Outcomes from HCPs’ appraisal of a situation include acceptance,withdrawal or emotional labour.

Tierney et al. Journal of Compassionate Health Care (2017) 4:1 Page 6 of 8

opinion and following their instructions, rather than eli-citing genuine shared-decision making [17]. ‘Being with’a patient may entail stepping away from health-relatedtasks for a moment and listening, being open to learningabout a patient’s situation in a non-judgmental, calmmanner [18]. However, it may be hard to be present dueto workload, tiredness and competing demands affectingconcentration [19]. Likewise, taking a mechanistic ap-proach to care, focusing on technology and technicalskills, may put HCPs at risk of disengaging from the pa-tient before them [20], resulting in staff doing for ratherthan being with patients [21].It may be beneficial to assist HCPs to develop coping

resources that allow for positive re-appraisal (“I havedone all I can but the patient is not ready to changeyet”) and to seek external support (expressing how theyfeel to colleagues) when faced with a patient who seemsunwilling or unable to manage their condition. Taken-for-granted ways of acting may not hold for some pa-tients depending on their circumstances and beliefs orvalues. Initiatives have been tried in practice (e.g. Balintgroups and Schwartz rounds) to allow HCPs to reflecton interpersonal and emotional aspects of undertaking acaring role, but they are not available in every settingand do not deal with emotional distress in real-time,which may affect delivery of CC.Study findings emphasised the emotional work under-

taken by HCPs when faced with patients regarded asnon-adherent. This links to previous writings on emo-tional labour, which defines strides individuals take intheir work life to manage their emotions so they providea publically-acceptable persona that meets with an orga-nisation’s expectations [10]. As part of this concept,emotional expression is seen as being governed by socialrules, which may be specific to a setting. Employeescome to learn the rules associated with their workplaceby watching colleagues; in healthcare, this is reinforcedby policy and institutional documents. It is argued thatemotional work within healthcare is devalued because itis regarded as a natural activity [22], instinctive [23].However, our research has highlighted that it involves acomplex interplay between person-environment andcognitive-behavioural appraisals (see also [24]); this reit-erates the point that CC is not necessarily a spontaneousor innate response but calls for reasoning and reflection.Hence, although actions associated with emotional workmay be seen as minor and non-technical, they can requireconsiderable personal investment and effort [25]. This wasemphasised in the narratives from participants involved inour study, who often talked about the exhausting and test-ing nature of remaining compassionate when faced withpatients who they appraised to be jeopardising their pro-fessional and personal goals and values by being, in theparticipants’ words, ‘non-adherent’.

ConclusionsIn a study exploring the meaning of CC for HCPs caringfor patients with type 2 diabetes, a key topic within partici-pants’ narratives was that of non-adherence among patientsas a barrier to CC. Our findings enable an appreciation ofCC from a new angle; for the first time, we used a model ofemotions and interpersonal relationships, outlined byLazarus and Folkman [9], to consider the difficulties HCPsexpressed about their interactions with such patients. Usingthis as a framework suggested that pre-requisites of CC in-clude perceiving the situation as not too threatening to per-sonal or professional status, or welcoming it as a challenge,and also feeling one has the resources available to cope.This may include valuing patients’ right to choose forthemselves how to behave, believing one is able to make adifference even if unable to influence someone’s physicalhealth, having colleagues who are supportive, and not feel-ing overwhelmed by external demands (e.g. targets, audits,being short staffed) so one has the headspace to form aplan of action. All participants talked about having therequisite health-related skills and knowledge, but CC wasabout how they evaluated and approached interactions,dealt with negative emotions and accepted blocks in im-proving a patient’s condition. These are areas that could beaddressed during training and post-qualification.

AbbreviationsCC: Compassionate care; HCP: Healthcare professional

AcknowledgementsWe would like to thank all the HCPs who took part in an interview or focusgroup.

FundingThis study was funded by the Royal College of Nursing Research Institute.

Availability of data and materialThe datasets generated and/or analysed during the current study are notpublicly available because the ethics committee did not provide approval forthe sharing of data in this way.

Authors’ contributionsThe first author was responsible for all data collection, led on data analysisand on writing this paper. The remaining authors played an equal role ininterpretation of data and contributing to the final publication. All authorsread and approved the final manuscript.

Competing interestsThe authors declare that they have no competing interests.

Consent for publicationNot applicable.

Ethics approval and consent to participateEthics approval was provided by the University of Warwick’s Biomedical andScientific Research Ethics Committee (Ref: REGO-2015-1424). All participantsgave their consent to involvement and use of their anonymised quotations.

Author details1Royal College of Nursing Research Institute, University of Warwick, Coventry,England. 2Social Science and Systems in Health, University of Warwick,Coventry, England.

Tierney et al. Journal of Compassionate Health Care (2017) 4:1 Page 7 of 8

Received: 17 November 2016 Accepted: 22 December 2016

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